Crown and Bridge Consent Form

Larry N. Balli, D.D.S.

1123 South 10th

Edinburg, TX 78539

(956) 318-3384

Informed Consent______

Crown and Bridge

1.  I understand that tooth number _____ needs a crown or a replacement of the existing crown. I have been informed of treatment alternatives or lack of treatment and the consequences there of.

2.  I understand that I need a bridge to replace tooth/teeth number (s) ______. Treatment alternatives include implant(s) or partial dentures.

3.  I understand that tooth decay may result in the need for a build-up filling, root canal therapy, or extraction of the tooth; all or any of which may result in increased treatment costs.

4.  I understand if local anesthesia is necessary, that complications can result, including, but not limited to prolonged or permanent numbness of the lips, cheek, teeth, chin, or tongue, swelling, sedation and/or allergic reaction.

5.  I understand that no dental restoration is considered permanent and may require replacement.

6.  I understand that the preparation of a tooth for a crown or bridge can result in the need for root canal therapy or in the loss of the tooth or teeth.

7.  Any unexpected or unfortunate outcome can result in the need for more extensive and more expensive dental procedures.

8.  I understand that an effort will be made to match my new restoration(s) to my existing tooth color, but that an exact match is extremely difficult to achieve any that a difference may be noticeable.

9.  I understand that covering a tooth with a crown or a bridge retainer does not make it immune from decay and that good oral hygiene is necessary to prevent this occurrence.

10.  Local anesthetic will be used for this procedure. The possible side effects of local anesthetic can include prolonged or permanent numbness of the cheeks, lips tongue and gums, rapid heart rate, allergic reaction, and/or reactions to other drugs that you are taking.

Signed______Date______